JOURNAL OF MEDICAL INTERNET RESEARCH
Östlund et al
Original Paper
3D Visualization as a Communicative Aid in Pharmaceutical
Advice-Giving over Distance
Martin Östlund1,2, MSc, PhLic; Nils Dahlbäck3, PhD; Göran Ingemar Petersson1, MD, PhD
1
eHealth Institute, Linnaeus University, Kalmar, Sweden
2
School of Computer Science, Physics and Mathematics, Linnaeus University, Kalmar, Sweden
3
Department of Computer and Information Science, Linköping University, Linköping, Sweden
Corresponding Author:
Martin Östlund, MSc, PhLic
eHealth Institute
Linnaeus University
Kalmar, SE-39182
Sweden
Phone: 46 480 497726
Fax: 46 480 497110
Email: martin.ostlund@lnu.se
Abstract
Background: Medication misuse results in considerable problems for both patient and society. It is a complex problem with
many contributing factors, including timely access to product information.
Objective: To investigate the value of 3-dimensional (3D) visualization paired with video conferencing as a tool for pharmaceutical
advice over distance in terms of accessibility and ease of use for the advice seeker.
Methods: We created a Web-based communication service called AssistancePlus that allows an advisor to demonstrate the
physical handling of a complex pharmaceutical product to an advice seeker with the aid of 3D visualization and audio/video
conferencing. AssistancePlus was tested in 2 separate user studies performed in a usability lab, under realistic settings and
emulating a real usage situation. In the first study, 10 pharmacy students were assisted by 2 advisors from the Swedish National
Co-operation of Pharmacies’ call centre on the use of an asthma inhaler. The student-advisor interview sessions were filmed on
video to qualitatively explore their experience of giving and receiving advice with the aid of 3D visualization. In the second study,
3 advisors from the same call centre instructed 23 participants recruited from the general public on the use of 2 products: (1) an
insulin injection pen, and (2) a growth hormone injection syringe. First, participants received advice on one product in an
audio-recorded telephone call and for the other product in a video-recorded AssistancePlus session (product order balanced). In
conjunction with the AssistancePlus session, participants answered a questionnaire regarding accessibility, perceived expressiveness,
and general usefulness of 3D visualization for advice-giving over distance compared with the telephone and were given a short
interview focusing on their experience of the 3D features.
Results: In both studies, participants found the AssistancePlus service helpful in providing clear and exact instructions. In the
second study, directly comparing AssistancePlus and the telephone, AssistancePlus was judged positively for ease of communication
(P = .001), personal contact (P = .001), explanatory power (P < .001), and efficiency (P < .001). Participants in both studies said
that they would welcome this type of service as an alternative to the telephone and to face-to-face interaction when a physical
meeting is not possible or not convenient. However, although AssistancePlus was considered as easy to use as the telephone, they
would choose AssistancePlus over the telephone only when the complexity of the question demanded the higher level of
expressiveness it offers. For simpler questions, a simpler service was preferred.
Conclusions: 3D visualization paired with video conferencing can be useful for advice-giving over distance, specifically for
issues that require a higher level of communicative expressiveness than the telephone can offer. 3D-supported advice-giving can
increase the range of issues that can be handled over distance and thus improve access to product information.
(J Med Internet Res 2011;13(3):e50) doi:10.2196/jmir.1437
KEYWORDS
Pharmaceutical instruction; 3D visualization; distance communication
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Introduction
People are not very good at using their medications correctly.
It has been shown that only about 50% of all patients manage
to follow the instructions they have been given to the full [1-3].
The effects of this failure to comply with given instructions are
serious. Nearly half of all medication-related admissions to
hospital are directly related to the patients not following their
prescriptions [4]; and 8%–10% of the total number of hospital
admissions are directly related to incorrect use of medication
[5]. Many different strategies have been attempted to improve
on the situation. In a comprehensive review of intervention
studies, Haynes et al [6] list the following interventions as the
most promising to improve compliance: providing more and
better instructions, fostering a good relationship between the
health care professional and the patient, scheduling regular
follow-up meetings, and supplying the patient with appropriate
reminders. The list shows that patient–caregiver communication
is very important in fostering good use of medication.
Many types of communication tools have been tried out in the
health care domain, and experience shows that the technology
does not need to be advanced to be helpful. Indeed, many
positive results have been achieved with simple solutions. For
instance, many studies have investigated the usefulness of
email-type messaging between patient and physician [7-11]
and, of course, the telephone is a well-established tool for
patient–caregiver consultation [12,13]. More sophisticated
communication technologies such as video conferencing and
groupware solutions have also been used, for example to review
patient data [14,15] or to discuss medical imaging data such as
from scans [16]. Results have been positive and, although initial
costs can be high for the more high-tech variants, distance
communication solutions of this kind have generally been shown
to be cost effective [17-19].
In this paper we explore the usefulness of 3-dimensional (3D)
visualization technology as a communication tool. 3D
technology has been put to good use in medicine, for example
in the exploration of scanning data [16], laparoscopic surgery
training [20], and phobia therapy [21]. However, it has not been
used to any great extent as an instrument of communication. In
other domains, most prominently that of computer-aided design
[22], it has been used as a communication enhancer for some
time, for example to support remote collaboration between
geographically dispersed teams [23-25], to review designs over
distance [26-28], and to offer training and support to remotely
located service personnel [29].
One exception where 3D technology has been used to support
communication in health care is with the use of 3D virtual
worlds such as Second Life. Second Life has been used in
medical training to provide a virtual meeting place for
health-related dialogue and for disseminating health care
information [30,31]. This is an interesting exploration into the
realm of possibilities that 3D technologies offer, but it is not a
practical solution for most types of caregiver–patient
communication.
In the health care domain, the preference seems to have been
either for technical solutions that are very simple, such as
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Östlund et al
email-based messaging systems, or for those that are very
advanced, such as state-of-the-art video conferencing systems
or virtual worlds. The problem is that simple solutions might
reach many people, but the expressive power is often limited.
Advanced solutions have more expressive power, but the number
of people who can be reached may be limited because they
might not have the required hardware or software, or they find
it difficult to use. The challenge is to find a solution that gives
room for expressiveness but also can be made available for a
broad audience.
The objective of the present exploratory descriptive study was
to examine the value of 3D visualization as a communicative
aid in pharmaceutical advice-giving over distance. We created
a Web-based application named AssistancePlus that uses
interactive 3D representations to demonstrate handling
instructions for complex pharmaceutical products. For the
application to be useful in practical terms, it needs to be easy
to access and easy to use for members of the general public.
Thus, the application also presents a proof-of-concept that an
advanced technology such as 3D visualization can be packaged
and presented in such a way that the resulting application is
accessible to this group. We carried out two evaluation studies
to investigate its practical usefulness for pharmaceutical
advice-giving. Comparisons were made with telephone
communication and face-to-face interaction in terms of
expressiveness and accessibility.
Methods
Materials
AssistancePlus is a communication tool that uses
co-manipulation of 3D representations of products, audio/video
communication, and co-browsing to support advice-giving on
pharmaceutical products over distance. Building on Clark’s
theory of communication and specifically his theory of common
ground [32-34], we believe that using interactive virtual 3D
objects together with audio/video communication will support
communicative efficiency by creating a sense of co-presence
between the patient and advisor. Our hope is that this will
translate into a natural feel to the communication, as well as
providing a high level of expressiveness.
AssistancePlus has been tailored to meet the specific needs of
the 2 parties involved in the advice-giving interchange: the
advice seeker and the advisor. The advice seeker is typically a
novice and a beginner—a novice to the content domain and a
beginner at using the communication tools at hand. The advisor
is an expert and a professional—an expert in the content domain
and a professional at using the communication tools (see [35,36]
for a similar description of the advice seeker–advisor
relationship). Due to the different nature of the 2 roles, their
needs and wants are different. The advice seeker wants a service
that is easy to access and easy to use. The advisor wants a
service that allows him or her to communicate efficiently and
effectively. This is achieved easily enough by providing them
with different versions of the user interface. However, although
it is true that most of the information in an advice-giving setting
flows from the person giving advice to the person receiving
advice, it is also necessary to have a flow in the other direction.
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No advice-giving session should be considered complete until
the advice seeker has internalized the given information—that
is, not only has received the information, but also has understood
it and is motivated to act in accordance with what has been
learned (see, for example, Clark [32,33]). It must be the
responsibility of the advisor in the role of expert professional
to make sure that this is so, and to do this the advisor needs
feedback from the advice seeker. Therefore, it is important that
advice seekers also can be expressive so that they can signal or
demonstrate their understanding back to the advisor. The
challenge here is to provide the right level of expressiveness
for each party and, for the advice seeker, to find an appropriate
Östlund et al
balance between ease of use and expressive power. Details on
how this challenge was approached in the design of
AssistancePlus can be found in Multimedia Appendix 1, together
with a technical description of the service.
Figure 1 shows a screenshot of AssistancePlus with the first
version of the 3D player being used to demonstrate handling
instructions for an asthma inhaler. The main features of
AssistancePlus are (1) co-manipulation of shared 3D objects
representing pharmaceutical products, (2) two-way text and
audio/video communication, and (3) co-browsing of webpages
with synchronized page scrolling and remote cursors
Figure 1. AssistancePlus, a tool for 3-dimensional (3D) -supported advice-giving on pharmaceutical products over distance
Evaluation Studies
The value of 3D-supported advice-giving was assessed in 2
separate studies, both set up in the same way. Study participants
(advice seekers) were exposed to AssistancePlus in a realistic
usage situation after which they were questioned about their
experience. The first study was explorative and probed the
general usefulness of 3D visualization for advice-giving
purposes. The second study was focused on the details of how
3D visualization contributed to raising the level of expressive
power. A telephone session was included in the second study
to provide an explicit (and controlled) reference point with
which to compare their experience with AssistancePlus. The
type of questions that AssistancePlus is appropriate for was also
examined. A large amount of data was collected in the 2 studies,
of which a selection is presented here (the full range of the data
is presented in [37]).
User Study I: Simple 3D Player
The objective of this substudy was to broadly explore the issue
of how 3D visualization can be used as a tool for advice-giving
on pharmaceutical products.
Materials
The AssistancePlus application, with version 1 of the 3D player,
allowed advice seekers to communicate with an advisor over
distance using 2-way audio/video communication and
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co-browsing of webpages (see Multimedia Appendix 1 for a
description of AssistancePlus and the 3D player). We made 2
webpages available for the advice seekers and adviser to browse
together: (1) a text-based page with general information about
the product (side effects, storage directions, etc), and (2) a page
with a 3D model of an asthma inhaler (Ingelheim; Boehringer
Ingelheim GmbH, Ingelheim, Germany) (Figure 2).
Participants and Recruitment
Playing the role of advice seeker were a group of 10 pharmacy
students (9 women and 1 man; age range 22–40 years).
Pharmacy students, with obvious preknowledge of the subject
area, were selected because their professional insight into the
subject area was considered helpful at this explorative stage
(the pharmacy students had no connection with the
AssistancePlus project and received no reward for participating
in the study). The students assumed the role of a relative of an
asthma patient (the role of relative is relevant because many
people are involved in their relations’ medication, and it was a
more realistic role for the pharmacy students to play than
patient). The role of advisor was assumed by 2 licensed
pharmacists from the National Cooperation of Swedish
Pharmacies’ call centre (both women; age range 40–50 years,
each with several years’ experience with telephone consultation).
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Procedure
Data Collection
The study was performed in a usability lab using standard
computer equipment and software (Web browser). Advice
seekers and advisors were in separate rooms and did not meet
each other before or after the trial. Advice seekers, who were
assigned the task of trying to find out as much as possible about
the inhaler, interacted through AssistancePlus for 15 minutes
with a randomly assigned advisor. No special instructions were
given on how much time to spend on any specific topic. The
first author conducted individual in-depth, semistructured
interviews on a separate occasion, 1 hour each for the pharmacy
students and 2 hours each for the advisors.
The students and advisors were filmed on video to allow for
analysis of the advice seeker–advisor interaction. The video on
the students’ side recorded keyboard and mouse use as well as
the screen; and the video on the advisor side recorded only the
screen. The audio from the interview was recorded, transcribed,
and summarized.
A semistructured interview was administered on a separate
occasion. The interview covered the following areas: general
impressions; specific impressions concerning audio and video
features, co-browsing features, and 3D; locus of control
(self/advisor); level of activeness (self/advisor); usefulness of
service; and target audience.
Figure 2. The Ingelheim asthma inhaler displayed using the first version of the 3-dimensional player
User Study II: Advanced 3D Player and Comparison
With Telephone
The objective of this substudy was to compare the experience
of using AssistancePlus with that of the telephone; to identify
the type of questions for which use of AssistancePlus is
appropriate; and to investigate the dynamics of how 3D
visualization contributes to communicative expressiveness.
Materials
As in the first study, AssistancePlus, with the second version
of the 3D player, was used to allow advice seekers to
communicate with an advisor over distance with 2-way
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audio/video communication and co-browsing (Multimedia
Appendix 1). As in the first study, 2 webpages were available
to the participants: (1) a text-based page with general
information (side effects, storage directions, etc), and (2) a page
with a 3D model, this time either of a pen injector for insulin
glargine (Lantus OptiSet, sanofi-aventis, Paris, France) or of a
disposable syringe for human growth hormone equivalent
(Genotropin MiniQuick, Pfizer, New York, USA). Figure 3
shows screenshots of their respective 3D representations as
displayed with the second version of the 3D player (Multimedia
Appendix 1; see also Multimedia Appendix 1 for additional
screenshots of the 3D sequences used).
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Figure 3. The 2 pharmaceutical products used in the second user study displayed using the second version of the 3-dimensional player: Lantus OptiSet
(left) and Genotropin MiniQuick (right)
Participants and Recruitment
For the role of advice seeker, 23 participants were recruited
from various night-school classes: 13 women and 10 men with
varied backgrounds, interests, and ages (18–74) (participants
received a nominal gift in the form of a lottery ticket with a
value of less than $10). As in the first study, the participants
played the role of a relative, this time of a patient with either
diabetes (Lantus OptiSet) or a growth hormone deficit
(Genotropin MiniQuick). The role of advisor was assumed by
3 licensed pharmacists from the National Cooperation of
Swedish Pharmacies’ call centre (2 women, ages 36 and 40
years; and 1 man, age 50 years), each with several years’
experience with telephone consultation.
Procedure
The advice seekers were instructed to try to find out as much
as possible about the 2 products, first using the telephone for
one product and then, on a separate occasion, using
AssistancePlus for the other product. The telephone condition
was first for all participants. The telephone session was
conducted from home, while the AssistancePlus session was
carried out in a usability lab. Advice seekers and advisors were
in separate rooms and did not meet each other before or after
the trial. Each session lasted 10 minutes. The order of the
products was balanced, with 12 advice seekers starting with
Lantus OptiSet and 11 starting with Genotropin MiniQuick.
The advisors were randomly assigned with a different advisor
in the AssistancePlus session and the telephone session. After
the AssistancePlus session, the advice seekers filled in a
paper-based questionnaire and then participated in a 20-minute
semistructured interview led by the first author.
Data Collection
The audio from the telephone sessions was recorded. The
AssistancePlus sessions were filmed on video and the screen
image was recorded. Questionnaire data were collected and the
audio from the interviews was recorded. The questionnaire
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covered the following areas: background demographic variables,
general attitudes toward computers and the Web, impressions
of AssistancePlus and its 3D features, comparisons between the
telephone and the AssistancePlus session, and which channel
(medium) they would use to inform themselves about
pharmaceutical products of varying complexity. In the
comparison between the telephone and the AssistancePlus
session, participants were asked to distribute 10 points between
the telephone and AssistancePlus for each of the following 7
factors: ease of use, ease of communication, sense of personal
contact, explanatory power, level of understanding, level of
trust, and efficiency. For example, if AssistancePlus is given a
rating of 6 on ease of use, the rating for the telephone for this
factor must be 4, to make a total of 10. (The factors were gleaned
from a discussion seminar held with representatives from the
pharmaceutical industry, health care representatives, and
advice-giving professionals [38].) Participants were also asked
which channel they would choose to inform themselves about
products of varying complexity level. In addition to telephone
and AssistancePlus, they were able to choose from pharmacy
store and the Internet, which were added to provide a more
complete range of alternatives (note that the participants’
acquaintance with AssistancePlus and telephone channels was
controlled in the study, but that with the Internet and the
pharmacy store channels were based on uncontrolled personal
experience). Participants were asked to distribute 10 points
among these 4 channels for each of the following 4 product
types: simple nonprescription medications, simple prescription
medications, complex prescription medications, and complex
medications requiring handling. The interview questions focused
on their experience of the 3D features and covered the following
areas: perceived level of expressiveness, experience of 3D
content, sense of presence, level of activeness, and locus of
control.
Statistical Analysis
For each of the 7 factors on which telephone and AssistancePlus
were compared, a set of preference scores were calculated by
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subtracting the rating given to the telephone from that given to
AssistancePlus (a positive preference score thus indicating a
preference for AssistancePlus and a negative score indicating
a preference for the telephone). Wilcoxon signed rank test was
used to assess the statistical significance of the preference
scores. Friedman tests were used to assess whether the
complexity level of the product affected the choice of
communication channel. Descriptive statistics were calculated
for other survey data.
Results
Findings From User Study I: Simple 3D Player
Being accustomed to telephone consultation, the 2 advisors
could make an experience-based comparison between using the
telephone and using AssistancePlus to give advice. The advisors
welcomed the power of expression the 3D content provided.
They felt that this extra expressiveness made it possible to
handle more complex issues than could be dealt with using the
telephone. In particular, the advisors valued the potential for
increased precision, for example that they could rotate and zoom
in on the model and then use their remote cursor to point to the
exact detail they were referring to in their spoken
communication.
The participants in the role of advice seekers were also pleased
with their experience of AssistancePlus, both in general and
with the 3D features specifically. All of the participants found
the 3D features useful as a pedagogical aid and found the
experience informative. The reasons they gave varied in
wording, but centered on issues of clearness and distinctiveness.
Several of the participants (7/10) also described the interaction
as similar in feel to that of a face-to-face conversation
concerning both level of expressiveness and sense of personal
contact.
One somewhat surprising finding was that the activity level of
the advice seekers was seemingly not very high. None of them
attempted to use the 3D controls themselves and only 1 used
the remote cursor purposefully. Reasons for not being more
active given in the interviews were that they felt they might
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disrupt the advisor (6/10 participants), that the content
“belonged” to the advisor (5/10), and that they felt a bit
intimidated by the many buttons on the 3D player control panel
(3/10). However, the main reason was that they did not feel it
necessary to be more active than they were. They were active
with their voice and, if they wanted to see a different view of
the 3D model, they could simply ask the advisor. This said, the
advice seekers wanted to keep the feature (9/10). It seems that
knowing that they had the option to control the model made
them feel more involved in the advice-giving process (even if
they did not actually do this). Similarly, the advisors felt that,
while the vocal feedback the advice seekers gave was sufficient
for the advisors to judge understanding in the present situation,
in other situations it might be helpful having the advice seekers
control the model themselves to demonstrate what they have
learned.
Findings From User Study II: Advanced 3D Player
and Comparison With Telephone
Figure 4 shows the median value, interquartile range, and total
range of the preference scores that were calculated by
subtracting telephone ratings from AssistancePlus ratings for
each of the 7 factors on which telephone and AssistancePlus
were compared (see Methods section). All the preference scores
were positive in AssistancePlus’ favor, and all scores except
ease of use were shown to be statistically significant (Table 1).
For ease of communication, personal contact, and trust, the
magnitude was moderate; for explanatory power, understanding,
and efficiency it was more pronounced. The results were
corroborated in the interviews, where participants described
their experience with AssistancePlus as being more clear and
expressive, being more personal and present, and giving a deeper
sense of understanding. Also, several participants described the
feel of the interaction when using AssistancePlus as being more
similar to a face-to-face meeting than that of a telephone
conversation. It should be noted, though, that both the
questionnaire and the interview were administered in
conjunction with the AssistancePlus session, which might have
introduced a positive bias in AssistancePlus’ favor, being the
more recently experienced.
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Figure 4. Preference scores comparing AssistancePlus and telephone. Positive scores (above the 0 baseline) indicate that AssistancePlus received a
higher rating. The vertical lines show the total range, the filled blue sections show the interquartile ranges, and the horizontal red lines show the median
values
Table 1. Preference scores comparing AssistancePlus and telephone (N = 23)
Z score
a
2-tailedb
(Wilcoxon
Median
a
Factor
(quartile deviation)
Mean (SD)
signed-rank test)
P value
Ease of use
0 (3)
1.04 (2.69)
–1.596
.110
Ease of communication
2 (3)
2.26 (2.58)
–3.448
.001
Personal contact
2 (4)
2.26 (2.43)
–3.454
.001
Explanatory power
4 (4)
4. 22 (2.63)
–4.042
< .001
Understanding
4 (4)
3.57 (2.63)
–3.758
< .001
Trust
0 (2)
1.48 (2.78)
–2.401
.016
Efficiency
4 (3)
3.96 (2.06)
–4.078
< .001
Based on negative ranks for [AssistancePlus score] – [telephone score].
b
H0: no difference between scores.
Figure 5 displays the results of the preference ratings given for
the 4 types of products and 4 different channels. On type of
product (front to back in Figure 5), the variation was found to
be significant for all product categories except complex
medications (Table 2). On type of channel (left to right in Figure
5), AssistancePlus and Internet differed significantly, but
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telephone and pharmacy store did not. The results indicate that
the advice seekers prefer a simple channel for simpler questions
and a more powerful channel for more complex questions—that
is, that they make their choice with consideration to the
complexity of the issue at hand.
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Figure 5. Relative preferences among information channels for different levels of product complexity (prescr = prescription, req = requiring)
Somewhat surprisingly, though, the advice seekers did not rate
the face-to-face setting—ostensibly the most expressive channel
among the alternatives—as the preferred channel for the most
complex type. In fact, the results instead showed an inverse
relationship between the pharmacy store and product
complexity. The reason for this was revealed in the interviews.
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The participants saw the meeting in the pharmacy store not as
an expressive and personal face-to-face interaction, but as a
fleeting encounter in a nonprivate, noisy, and stressful
environment. The telephone received surprisingly low ratings
for all categories indicating that the telephone is simply not a
popular alternative when seeking medical advice.
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Table 2. Friedman tests on preferences among information channels (N = 23)
Type of product
Telephone
AssistancePlus
Pharmacy
Internet
Simple nonprescription
Simple prescription
Complex
Requiring handling
0.70
1.09
4.70
3.52
SD
1.06
1.20
3.42
3.25
Mean
1.09
1.78
4.83
2.30
SD
1.35
1.93
2.95
2.40
Mean
1.43
3.17
3.61
1.83
SD
1.56
2.98
2.66
1.83
Mean
1.09
5.91
2.27
0.61
SD
1.31
2.25
1.86
0.89
3.329
43.01
5.949
24.53
.36
.001
.11
.001
P value
a
P value
(c )
Mean
Friedman test (c2)a
Friedman test
2 a
store
22.35
< .001
17.15
.001
7.608
.06
43.05
< .001
Two-tailed; df = 3 for all tests.
The level of activity on the part of the advice seekers was very
low in the first study, with none of them even attempting to use
the 3D controls. This behavior changed in the second study,
where they were more active. Typically, the actions they
performed were simple ones such as using their remote cursor
to point to details on the 3D model (16/23, 70% of participants),
moving the playhead to go to a specific point in the animation
(2/23, 9%), and starting and stopping playback (3/23, 13%).
Only 1 participant used the click-and-drag controls to rotate
and zoom in on the model. However, the preference for simpler
action was not because they did not know how to perform these
more advanced actions. As in the first study, they simply found
it easier to have the advisor do it for them. Still, the participants
were very positive about having the option to be able to control
the 3D content themselves (N = 23, mean [SD] 5.42 [0.90],
range 1–6) and wanted to keep the feature. The advisors were
also pleased that the advice seekers had the option to control
the 3D content themselves.
Discussion
We have shown that 3D visualization techniques paired with
video conferencing can be useful in supporting advice-giving
over distance and can be used even in low-bandwidth settings.
AssistancePlus offers a proof-of-concept of how 3D
visualization can be used to extend the range of questions about
pharmaceutical products that can be handled over distance.
Distance communication cannot, and should not, be used to
replace the physical meeting between patient and caregiver, but
in many situations distance communication can save time and
resources and give patients quicker and easier access to the
information they need. Haynes et al [6] listed more and better
information and fostering a good relationship with caregivers
as the 2 top interventions to improve compliance. We believe
that a service such as AssistancePlus can contribute to both of
these by making it easier for patients or clients to communicate
with their caregivers. We also found it interesting that in some
cases our participants actually preferred AssistancePlus to
face-to-face communication, as this usually takes place at the
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pharmacy. This illustrates our belief that Internet-based
communication not only should be seen as a substitute for
face-to-face interaction but also can in some cases offer a better
alternative.
Choice of Channel Based on Question Content
Advice seekers and advisors alike found AssistancePlus useful
as a pedagogical aid for advice-giving and particularly
appreciated the clarity and exactness brought to instructions by
the 3D features. This does not mean that AssistancePlus is the
right choice for all types of advice-giving situations. The results
from the second study indicate that information seekers do not
just go for the most expressive channel, but differentiate their
choice. Perceived level of expressiveness is one factor affecting
choice, but other factors are also important. For instance, the
pharmacy store was an unpopular alternative for the reason that
it was seen as lacking in privacy. If we try to isolate the issue
of level of expressiveness here, it seems that participants
preferred the channel that offers not too much, not too little, but
just the right level of expressiveness. The implication is that we
should provide advice seekers not with a single catch-all
channel, but with a selection so that they can choose the right
channel for the question at hand. Of course, the downside of
providing choice is that it places a burden on the advice seeker
to choose among an ever-increasing range of channels. We
believe that a major future challenge will be to provide guidance
services to help advice and information seekers to find not only
the right information, but also the right channel.
Empowering the Advice Seeker
In the advice-giving situation, most of the communication
naturally flows from the person giving the advice to the person
receiving the advice, but we have argued that it is important
that the advice seeker provide feedback so that the advisor can
properly judge understanding and motivation. Here, care must
be taken not to overwhelm or intimidate the advice seeker, who
perhaps for the first time is communicating over distance using
advanced technology. Our solution is to provide self-use of, for
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example, the 3D controls as an option, something that one can
do, but does not have to do.
An interesting—and we believe important—finding in this area
was that advice seekers did feel more involved when presented
with the option of using the 3D controls, but this sense of
involvement was not the result of actual action. Instead it seemed
to stem from the awareness that they could be active. Both those
who actively used the 3D controls and those who did not felt
empowered by knowing they could control the 3D content
(theoretical support for this empowerment effect can be found
in Clark’s theory of common ground [32-34]). This finding
suggests that it is positive to present advice seekers with more
functionality than they are expected to use. However, we
hypothesize that the empowerment effect will occur only if the
functionality is perceived as something they can manage. This
means that either the functionality needs to be simple enough
to be self-explanatory, or it can be easily explained by way of
demonstration, which is the case with the playback and 3D
controls used in the studies. We believe that this finding,
provided that it can be corroborated in further studies, can have
important consequences for the design of online communication
services of the kind presented here.
Östlund et al
Limitation of Study and Cost of Service
It must be noted that both presented studies used convenience
samples and were performed in usability laboratories. There
may also be a novelty effect, and it remains to be seen how a
service such as AssistancePlus would work in a real-world
setting with real patients and caregivers who might react
differently from the test participants in our studies. That said,
the results are promising and we believe AssistancePlus can
provide both an alternative to the telephone when it is not
expressive enough and a complement to the face-to-face
interaction when a physical meeting is not convenient.
We have not performed a detailed analysis of the cost of setting
up and running a service such as AssistancePlus, but it is our
assessment that it should be comparable with that of setting up
a telephone-based call centre. Of course, the easiest way to get
a service like AssistancePlus up and running would be to add
it to the list of services offered by an existing call centre. Since
all the functionality demonstrated in the AssistancePlus
application can be implemented using open source free software,
this means development and running costs can be kept down
and, while the production of the 3D content is an extra cost for
each product that is added, it is a cost of moderate size.
Adapting to the Specific Communication Situation
Conclusion
In this paper we have exemplified how 3D visualization can be
used in health communication for a specific advice-giving
situation. It is in the custom tailoring to the specific
communication setting and to its actors that the service gains
its edge, but we believe that the concept it presents—ease of
access with low technical and usability thresholds and a level
of expressiveness tailored to the demands of the specific
communication situation—is relevant for any area of health
care where there is a need for improving access to information
and for bringing patients and caregivers closer to each other.
We have shown that 3D visualization techniques paired with
video conferencing can be useful in supporting advice-giving
over distance and can be used even in low-bandwidth settings.
We also showed that 3D visualization brings clarity and
exactness to given instructions and contributes to communicative
efficiency. It is a technology that can be made available to the
general public and, if implemented with proper consideration
to the role and character of the advice seeker, will be both easy
to access and easy to use and, in some cases, even preferred to
face-to-face communication.
Acknowledgments
The AssistancePlus project has been sponsored through the eHealth Institute by the National Cooperation of Swedish
Pharmacies–Apoteket AB, Linnaeus University (previously University of Kalmar), the Regional Council in Kalmar County, the
Kalmar County Council, and the Municipality of Kalmar. The eHealth Institute is part of Linnaeus University. Thanks to Daniel
Fredriksson, who helped with the practical construction of the 3D models, and Lina Hellström, who advised on the content of
the 3D sequences.
Conflicts of Interest
The first author has founded a company – Instant Connect Sweden AB – for the purpose of exploring various commercial
applications of the described communication technology.
Multimedia Appendix 1
Technical description of AssistancePlus and screenshots of the second version of the 3D player displaying animation sequences
for Lantus OptiSet and Genotropin.
[PDF file (Adobe PDF File), 487 KB - jmir_v13i3e50_app1.pdf ]
Multimedia Appendix 2
Survey from user study II in English translation (original is in Swedish).
[PDF file (Adobe PDF File), 1025 KB - jmir_v13i3e50_app2.pdf ]
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Abbreviations
3D: 3-dimensional
Edited by G Eysenbach; submitted 21.12.09; peer-reviewed by F Amenta, J Sankaranarayanan; comments to author 18.06.10; revised
version received 25.05.11; accepted 26.05.11; published 18.07.11
Please cite as:
Östlund M, Dahlbäck N, Petersson GI
3D Visualization as a Communicative Aid in Pharmaceutical Advice-Giving over Distance
J Med Internet Res 2011;13(3):e50
URL: http://www.jmir.org/2011/3/e50/ doi:10.2196/jmir.1437
PMID:21771714
©Martin Östlund, Nils Dahlbäck, Göran Ingemar Petersson. Originally published in the Journal of Medical Internet Research
(http://www.jmir.org), 18.07.2011. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any
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